Failure to Maintain Accessible Survey Results Binder
Penalty
Summary
The facility failed to ensure that the Past Survey Results binder included the most recent recertification survey results and associated plans of correction for two of the past three years reviewed (2023 and 2024). During a review of the binder, it was found that the recertification survey results and plans of correction dated 03/24/2023 and 06/13/2024 were missing. The facility's policy required that survey reports, certifications, complaint investigations, and plans of correction for the preceding three years be available for review by any individual upon request, and that a copy of the most recent survey report and any plans of correction be kept in a binder in the residents' day room. Interviews with the DON and Administrator confirmed that the responsibility for maintaining and updating the Past Survey Results binder rested with the DON, and that the process involved placing survey results in the binder upon receipt. Both staff members acknowledged that the required documents for 2023 and 2024 were not present in the binder at the time of review. The DON stated that while survey results and plans of correction were accessible online and could be printed upon request, the physical binder did not contain the necessary documents, thereby preventing residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plans of correction.